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PMMA: A Good filler with a bad rap?

Article-PMMA: A Good filler with a bad rap?

In July this year Denis Cesar Barros Furtado, a doctor with questionable credentials in Brazil and known by his reported 650,000 Instagram followers as “Dr. Bumbum,” was arrested for the death of his patient who had several heart attacks after receiving buttocks injections. According to some news reports, Dr. Bumbum, known as the name implies for cosmetic buttocks procedures, injected the patient with polymethylmethacrylate (PMMA) and did the procedure in his Rio de Janeiro apartment.

The Brazilian Plastic Surgery Society has issued warnings about the use of PMMA, according to an August 17 UPI article. But Brazilian plastic surgeons also appear to support PMMA when it’s properly used in cosmetic patients. In a paper published June 5 in Aesthetic Plastic Surgery, the authors offered the Brazilian consensus recommendation for PMMA filler use in facial and corporal aesthetics. They recommended PMMA 30% filler in specific facial sites, including the nose, mentum, mandible angle, zygomatic arch and malar, but not in the lips, regardless of concentration.

The amount of PMMA recommended in the corporal sites is 50 mL in the calf and 100 to 150 mL in the gluteal region.

However, in real-world practice here in the U.S. some say PMMA isn’t worth the risks, including allergic reactions, lumps and bumps, for cosmetic patients. Others think it’s a good filler with a bad rap.

Angelo Cuzalina, M.D., D.D.S., chairman of the American Academy of Cosmetic Surgery cosmetic surgery fellowship program and former president of the American Board of Cosmetic Surgery, says he used PMMA “more as a form of bone cement” for reconstructive surgery of the face many years ago.

“However, PMMA is really not as popular anymore in the cosmetic field because of potential problems and the fact that so many better and safer options now,” says Dr. Cuzalina, who practices in Tulsa, Okla. “This is especially true for gluteal augmentation where I personally believe PMMA no place at all.”

On the other hand, West Hollywood, Calif., cosmetic dermatologist Jason Emer, M.D., is a fan of using the PMMA filler Bellafill (Suneva Medical) for filling acne scars and facial lines, such as the nasolabial folds. It’s FDA approved for those indications and is an effective treatment when injected in small quantities.

But like Dr. Cuzalina, he believes it’s not an ideal filler for the buttocks, Dr. Emer tells The Aesthetic Channel.

Dr. Emer says girls and women are influenced by the tight waists and large, lifted buttocks they’re seeing on social media. Patients might pursue the Brazilian butt lift (BBL), which involves injecting fat into the buttocks and has raised patient safety concerns among plastic surgeons, or they might opt for injections with fillers, including injectable poly-L-lactic acid (Sculptra, Galderma) or PMMA, which are off-label in the U.S.

“Any injectable can be dangerous particularly if injected deep in the muscle where the superior and inferior gluteal veins exist. Accidental injection into these deep veins with fat or other material can cause life threatening issues immediately,” Dr. Cuzalina says. “That is why both the American Board of Cosmetic Surgery and the American plastic surgery organizations have recently made statements concerning safety of injection into the buttock for augmentation. There have been issues even with very qualified board-certified surgeons.”

Sculptra takes time to build in the buttocks and can be prohibitively expensive, which has many who want bigger bottoms searching for other options, according to Dr. Emer.

“Some people are going to other countries to get injections of more permanent fillers, like silicone or PMMA. If you’re using the true silicone and PMMA that’s made in the U.S., those are extremely safe in micro-droplet quantities, injected very superficially in the skin. The syringe for PMMA is .8 cc,” Dr.  Emer says. “If you think of a regular BBL, people are injecting 500 to 1000 ccs per side. So, you would need on average 2500 to 3000 syringes of the PMMA to get any increase in size. When you do that you’re putting yourself at risk for clumping, lumps and bumps and irregularities because it’s not made to be injected in a large quantity.”

There’s also the risk of the filler going into blood vessels and causing deadly blood clots, according to Dr. Emer.

Another issue is the source of PMMA. Unless cosmetic providers purchase a known product like Bellafill, there’s no telling if it’s a clean, safe product, Dr. Emer says.

“It could be a manipulated product that has cement, chemicals or other ingredients in there that are dangerous,” he says. “Obviously you shouldn’t be going to hotel rooms and unsterile places to do these procedures. It should be in a medical facility.”

Dr. Emer says patients like PMMA because it has particles that help to build collagen long term.

“It’s great for acne scars because when you inject a little bit of it you get a lot of a result, which builds over time,” Dr. Emer says.

Dr. Emer says he’ll also use PMMA to treat facial wrinkles and nasolabial folds when patients aren’t ideal candidates for hyaluronic acid fillers because they metabolize the fillers too quickly.

“This is an alternative for them because it’s longer lasting. So, using small amounts over time, you can give somebody a filler effect on their face long term,” Dr. Emer says. “Some people have even used PMMA for nasal reconstruction, after having a rhinoplasty to fix lumps, bumps or indentations on the nose. I’ve used it after breast cancer reconstruction to reconstruct nipples.”

PMMA is a great option for treating small irregularities after liposuction or after traumatic accidents to fill indentations of face and body. It’s also good for cellulite, according to Dr. Emer.

Doctors should inject only well-known pure PMMA product in small quantities using a ‘microdroplet’ technique, according to Dr. Emer.

They should inject it slowly and steadily. And it’s best to use PMMA not for an immediate result but for a result that builds with time.

Dr. Emer generally injects Bellafill initially in a series of treatments, then maintains results with about two treatments annually.

Dr. Cuzalina says that he believes PMMA is best reserved for small areas in the face and only if it is an approved name brand. “Unlicensed products can be dangerous especially when used in high volumes deep in the body.  Who knows what is in some syringe if it is not obtained from a reputable company?”